“Home birth doesn’t need to be legalised – it is legal”

Ágnes Geréb, obstetrician/gynaecologist, psychologist, midwife, obtained her medical degree in Szeged in 1977. For many years, she worked as an obstetrician at the Szeged Obstetrical and Gynaecological Clinic. It was in 1989 that she firstassisted in a so-called planned home birth. In 2007, she was banned from the practice of medicine for three years. After the cases related to this accusation, Ágnes Geréb was recently named once again as a suspect in a case of negligent endangerment of life. It was in connection with this that she was placed in pre-trial detention, and subsequently under house arrest.

Based on related interviews in previous articles on home birth that appeared in the LAM, despite the pending criminal proceedings against her, but in full compliance with the regulations in force, she gave LAM and elitmed.hu this exclusive interview.

She is currently accused of four crimes, including causing the death of one infant. According to latest reports, the prosecutor is seeking a suspended sentence, and the final verdict is expected on 24 March 2011.

– Do you believe that only low-risk groups should give birth at home?

– A few years ago, I was practically fanatical in insisting that we only select places where the local hospital can be reached in no more than 20 minutes in average daytime traffic. It was often so hard to draw the line! 25 minutes? that doesn’t matter. Thirty-five minutes?…oh no, that’s too much! Then we held a midwives conference. We had participants from Canada, Germany, Holland, England, Poland, the Czech Republic, the US and Mexico. Since the first time when I met other midwives accompanying home births, at the world’s first international home-birth conference in London, I have felt, again and again, that the greatest benefit of these meetings is how we independent midwives encourage one another. Despite the wide variety in our circumstances, we all reach the same goal although we may take a great variety of different path. There is no better proof of the fact that we are headed in the right direction.

Ágnes Geréb

– Does some sort of professional consensus emerge?

– There are always one or two main highlights that I gratefully integrate into my own collection of experiences and that help me through certain difficulties. This is how I felt at this midwife conference when I heard a statement by a Canadian midwife. She said that her statistical results were exactly the same as those of any other home-birth midwife. That is, in the births at which she assists there are as many and the same types of complications as in any other part of the world. These are solved with just as much (or as little) success as elsewhere. Wherever there is – or has been – birth, there will be – and has been – death. One thing is quite different however: in the places where she accompanies home births, the nearest hospital is an eight-hour (!) drive away. I started thinking about this and it didn’t take me long to find the obvious explanation. It is gradually becoming a cliché (I hope) to say that everyone gives birth with the least complications where she feels safest. This is obvious, because insecurity and fear wreak havoc with the very motor of birth: the functioning of the hormonal system.

– Fear interferes with the process?

– Yes. This is why we should never, in any way, force someone to give birth in a certain place. Instead, we should give thorough and objective information about birth, including statistical indices for the places available: home or hospital, ideally broken down by individuals (hospital midwives, assistant midwives, ob/gyns, independent midwives) to ensure transparency.

– What are the bases for a sense of security?

– Among the many factors contributing to a sense of security, one of the factors which is the most important for the majority of women is the healthcare or “medical” issue, while another also very important element is the choice of location. Independent midwives do not promote home birth. They promote undisturbed birth. One of the conditions for the latter is that the decision is not motivated by external pressures or current trends, and that this decision is made not by the expert, but by the woman herself, in consultation with whomever she judges to be important in this respect. Ideally, in cases where interrelations are well-structured, the services offered by the independent midwife are there to help the pregnant woman or birthing mother to, up until the very moment of the birth, decide on or change her mind about where she wants to give birth without having to be separated from the midwife accompanying the birth. (Of course she should also be able to choose to continue the birth without the original midwife.) This is the so-called “primary care”, which means that the midwife is present in all phases – antenatal care, birth and postpartum – irrespective of the place of care. In this context, a “short-stay” hospital birth (i.e. where the mother leaves hospital soon after the birth) is different from how it is understood to be here. Our understanding of a short-stay birth is that the midwife accompanies labour at home, then at a certain point in labour she and the mother go to hospital together where the same midwife accompanies the birth, two hours after which they return home together. It doesn’t mean that the woman in labour stays at home for a long time without any expert care, then drops in to a hospital to give birth, then returns home, again without any expert assistance. But to return to the original question, if the distance from the hospital does not cause a sense of insecurity in a responsible, fully informed woman, then this factor will not have a negative impact on her birth. Thus, the likelihood of complications in her case will be exactly the same as if the hospital were closer. Whoever feels unsafe because of this eight-hour distance from the hospital will move closer – maybe four hours away, one hour, 20 minutes, or simply move into the hospital altogether. This is what the freedom to choose means.

– If an infant is born in hospital, he or she is automatically given an Apgar score. In fact, if the birth is difficult, a neonatologist is summoned to establish the one- and five-minute Apgar scores.Is this rating made at home births as well?What do you do if the infant’s condition is unsatisfactory?

– You don’t need a neonatologist to make an Apgar score. If there is a foreseeable need for a neonatologist, then the birth does not take place at home. The training and equipment of an independent midwife are designed for the accompaniment of pregnancies and births that shows all signs being free of complications. If complications arise at any stage, those are assessed, and the midwife begins to treat the complication while. If necessary, she will seek consultations, further tests, send the expectant mother to a specialist, or begins resuscitation efforts while calling for an ambulance and ensures transport to hospital if needed.

– During birth, certain life-threatening conditions can arise that require emergency care, such as when, despite impeccable CTG readings, an infant is born in a very poor condition, or the mother develops atonic haemorrhage. How can cases like these be dealt with in home births?

– The basic principle is the same. We begin the necessary treatment and meanwhile arrange for transfer, calling an ambulance. Fortunately, however much home birth may be criminalised, these life-threatening situations occur significantly less frequently in a home setting than they do in an institutional context. The favourable statistics of home births and birthing centres are due to the fact that we do not perform any routine interventions. Every single intervention, even the most minor, comes with risks. The risks may be small or they may be big, but there are always risks. If we do not perform interventions in cases where the process would unfold on its own without intervention, then we avoid introducing even these very minor risks into the process.

– What about the statistics of birthing centres? Do they reflect their in-between status?

– The reason that Hungary’s birthing homes had such bad statistics and had to be closed down was because they operated on a medical model without having the corresponding institutional backup. They would often carry out very minor interventions (like breaking the waters) which would lead to the need for another intervention, which would lead to another – like dominos, one leading to the next. Meanwhile, they did not have surgical facilities.

– What do you think would be the optimal model of care?

– If there were ob/gyns who would attend home births in accordance with the midwife model, that would be great. My concern is that there is not a single ob/gyn who has – if we say the smallest amount of time possible – four hours to devote to a single case, plus three hours, as specified by the Decree as of 1 April 2011, as that is the amount of time that the birth assistant must remain with the postpartum mother after the birth. Anyways, it would be an unnecessary luxury to use them for that purpose, that isn’t their job anyways. Their job is an essential one in safe home birth: to ensure humane, top quality institutional care that is always available, to work hand in hand with midwives as equals, and not in a hierarchical structure of subordinate and superior.

– In countries where giving birth at home is an option, subjects are selected on the basis of a very strict set of criteria.The equipment, qualifications and training of persons present, hospital transfer system and the necessary conditions for that.An example of the severity of the set of conditions is how in Holland, where home birth is most common, one group that provided home-birth accompaniment services in seaside towns refused to attend summer births because the summer tourist traffic caused travel time to the nearest hospital to be more than 15 minutes.What do you think of this?Can this be applicable in Hungary at all?

– Although the Dutch example has its well-founded reasons, it is a unique one, and I don’t think it can be generalised in any way. To be very honest, I would say that this is not true. It’s not true, because even in Holland, they don’t have an ambulance standing in front of the door for every single home birth. For 21 years in Hungary, the issue of home birth was more or less settled, so long as midwives were allowed to carry out their work undisturbed. Now it is not settled. I fear that the legislators, who are inexperienced in the issue, are creating unrealistic – what is more, dangerous – situations by TRYING TO REINVENT THE WHEEL, instead of simply building into our German-style system of obstetrics and gynaecology a German-style midwife system based on the corresponding existing practice.

– Years ago, the Hungarian College of Obstetricians and Gynaecologists drafted a set of rules for home birth.What is your view of this protocol?

– The College of Obstetricians and Gynaecologists can draft the protocol for obstetricians and gynaecologists, but not for midwives. For that, we need a College of Midwives. Which, if someone up there really did take the “legalisation” of home birth seriously, would soon be set up.

– Over the last few weeks, the home-birth system has been regulated.By the end of this process, home birth will be permitted in Hungary as well.What expectations do you have of the legalisation of home birth?

– Home birth doesn’t need to be legalised, it is legal. What needed to be legalised was the work of midwives. They had to enact legislation specifying what education and what practice is needed for independent, responsible midwives and independent, responsible mothers to decide what is most important for them. This is an approach which, I hope, will be accepted by all and by all healthcare professionals working in the area of births – hospital midwives, independent midwives, ob/gyns, public health nurses, etc. – to safeguard the physical and psychological health and well-being of mothers and infants to the highest degree possible. What I see in the decree currently being drafted is the propagation of the opinion that home birth is the decision of irresponsible mothers, assisted by irresponsible midwives, and that the role of the legislation is to protect infants from them. And the other thing that shows through the Decree is this gentlemanly ploy. Instead of treating home birth as basic care, once the decree comes into effect, only people with money will have access to it. It didn’t use to be like that…